Student Mandatory Education

Module 1

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Our Mission, Vision, and Values drive everything. They outline a way of life at work that will help you and MHS be successful. Let the mission, vision, and values become part of your actions each and every day.

Mission, Vision, and Values

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Our Mission is our reason for being. It is why we do what we do.

Mission

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Our Vision is what we setout to achieve.

Vision

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Our 5 Values

Our Values are how we behave.

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They are connected. We cannot achieve one without the other.

Summary

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The purpose of The Code of Conduct is to make sure that MHS meets the highest standards of excellence both legally and ethically. It is everyone’s responsibility to make sure that the principles outlined in The Code of Conduct are upheld.

The Purpose of the Code of Conduct

What do we mean by the Patient Experience

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• A Patient’s Experience is their perception of all interactions with Associates, Physicians and Volunteers as they progress through their continuum of care.

• Creating a positive patient experience is the responsibility of EVERYONE because every touch point makes a difference.

• In every interaction, our goal is to create peace of mind for the Patient and family members.

• Every person wearing a Martin Health System name badge that a patient sees in their room or walking in the hallway adds to their perception ( + or - ) of the experience.

• You make a difference irrespective of your job role.

Patient Experience

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Service Promise

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Our Service Promise is the way that we bring our mission, vision and values to life every day.

Service Promise

Created by us and our patients for us and our patients

Human Business Human

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• To create peace of mind, we make a human connection at the beginning of every interaction. This includes in person, on the phone and even in email. A simple good morning or good afternoon will work.

• Then we conduct our business with expertise and efficiency.

• Wrap up any interaction with another human connection such as a fond farewell.

Graffiti is defined as anything that distracts or detracts from the intended ideal patient and family experience.

We work constantly to eliminate the things our patients see, feel and hear that do not create peace of mind.

Graffiti

Operational Priorities

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We want to use all four of these in harmony to provide peace of mind. When there are conflicting priorities, use this order to make decisions.

In our patient driven Operational Priorities, our patients want us to provide care in this order: • Safety & Quality • Compassion • Expertise • Efficiency

On the Spot Recognition

When you see someone creating peace of mind for patients or for our team, recognize them with a Caring on the Spot card. Simply fill out the card and hand it to the person you want to recognize!

The HEART Model

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• Everyone is empowered to perform Service Recovery.

• Utilizing the HEART Model will

ensure a positive outcome, not only for the patient, but also for the person performing Service Recovery.

• If you cannot resolve a problem, then get help immediately by talking to your leader.

• Discuss solutions and agree on best action to solve the problem

• Follow up to make sure the customer is satisfied with the resolution. It is essential that we always follow through with what we have promised.

If you cannot resolve a problem

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The Martin Health Way tips: • Create peace of mind in every interaction. • Greet people in a warm and friendly manner, in the halls and

elsewhere; gain eye contact and smile. • Give people sincere care and concern, which establishes trust

and loyalty. • Ask how you can help. • Listen with empathy. • Walk with visitors to help them find their destination or

further assistance.

Ways to Provide Excellent Service

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• HCAHPS stands for Hospital Consumer Assessment of Healthcare Providers and Systems

• HCAHPS is a national, standardized publicly reported survey of patients’ perspectives of hospital care. It can be administered to patients’ from 48 hours to 6 weeks after discharge.

• HCAHPS measures key aspects of the patient experience via a survey sent out to our patients by a third party vendor (Press Ganey).

• The survey is nationally standardized and conducted by an outside agency. The results are publicly reported, available for all to see.

What is HCAHPS?

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• What our scores mean for Our mission – These HCAHPS measurements are a great way to see how

we are reaching our mission ‘to provide exceptional healthcare, hope, and compassion to every person, every time’.

• What our scores mean for Our facilities – The survey provides us with feedback, helping us to

continuously improve – We can see how we are performing in relation to other

providers. – High scores show positive patient experience of care.

Positive patient experience can lead to fewer re-admissions, which is good for the patients!

What is HCAHPS

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The HCAHPS survey asks patients how well and how often we responded to their needs:

Ultimately, it is asking how we made them feel!

What the HCAHPS Survey Asks

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Never Sometimes Usually Always

What the HCAHPS Survey Measures

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Our Patients, their families and visitors along with our colleagues come from a diverse range of cultures. Diversity is about acceptance, understanding and respect in a safe, positive and nurturing environment. Diversity includes the various scopes of race, ethnicity, gender, sexual orientation, socio-economic status, age, physical abilities, religious beliefs, political beliefs, generations or other principles. We aim to be inclusive in all our interactions. Your awareness , understanding and respect for cultural differences will help you provide exceptional health care, hope and compassion, every person, every time.

What is Diversity

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• Here are some areas of potential cultural differences. Considering these areas can help you make sure that you are meeting needs respectfully.

• People have – Different accents – Different languages – Different rules relating to eye contact – Different personal space boundaries – Different roles of who make the decisions in the family – Different on devoting time to come for follow-up care – Different health focuses – Different healthcare resources – Different beliefs

• Awareness of cultural backgrounds helps us to provide respectful, competent, and

appropriate care to every person, every time.

• Cultural sensitivity helps limit judgment of others

• If you are unfamiliar with someone’s culture, ask them to help you understand what would be helpful to know when providing care to them and their family.

Potential Cultural Differences

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• The top 3 causes of death in the US are – Cancer – Heart disease – Preventable medical errors

• Preventable medical errors cause 1,000 deaths per day. This could be compared to two 747 planes crashing per day.

• Medical errors are a huge concern and even the best person can make mistakes, but it is important to always try to prevent medical errors.

*July 2014: Tejal Gandhi, MD, president of the National Patient Safety Foundation and associate professor of medicine, Harvard Medical School, Senate hearing, Washington DC

Preventable Medical Errors

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• Some actions that you can take to prevent medical errors are to: – Check Identifiers (name and date of birth) – Slow down and do not multi-task when you are doing

something important (Do not rush so much that you are not paying attention)

– Think about what you are doing to verify that it is correct

– Regularly verify that the system or process is working correctly

– Verify e-mails, phone numbers, and fax numbers – Follow protocol and policies (If you think there is a

better way, then tell your leader about your idea. Do NOT just start doing something differently.)

Preventing Medical Errors

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For additional information: → National Quality Forum

website

Patient Safety

Module 2

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1. Identify patients correctly 2. Improve staff communication 3. Use medicines safely 4. Use alarms safely 5. Prevent infection 6. Identify patient safety risks 7. Prevent mistakes in surgery

7 National Patient Safety Goals for 2018

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To avoid errors such as wrong information, wrong treatment etc., correct patient identification is extremely important. We use 2 identifiers to cross check - name and date of birth. A 2-step method for checking is conducted for every patient, every time! 1. Ask patients to state their full name and date

of birth 2. Verify by checking the patient’s armband

Correct Identification of Patients

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• Be aware of what is going on around you! – If you don’t know or understand what is going on, then ask – If you hear or see something that you think needs to be

addressed, please notify someone. Remember, voicing a concern is done out of care for others. You can notify: Your chain of command The person in charge in the location that the situation occurred Compliance Hotline 877-785-0002 Corporate Compliance Risk Management Patient Experience

– For example, if you see a patient doing something that you do not think is normal then communicate with someone to address it.

Communication and Our Mission Contact Information: → Compliance Hotline 877-

785-0002 → Compliance Department

at ext. 11983 → Compliance Officer at

ext. 13957 → Risk Management at

ext.15899 → Patient Experience 771-

223-4995

4

• Healthy Groups that foster a culture of positive communication will: – Demonstrate a willingness to work through conflict rather than

avoid it – Demonstrate a willingness to listen and pay attention to one

another – Focus efforts on addressing one topic of discussion at a time – Help members feel comfortable in sharing thoughts & ideas – State decisions clearly so that all members can understand the

outcomes – Provide avenues for feedback – Maintain consistent communication processes to help the group

stay focused on its goals

Positive Communication

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• Tips for listening – Conversations means talking ‘with’, NOT ‘at’ someone – Keep yourself fully engaged – Ask yourself, have your ever felt this way, did

someone listen to you? – Focus on what is being said, not on what you want to

say – Value listening more highly than speaking – If you don’t agree or understand – let the speaker

know why, be open to differences – Clarify feelings – Remember, people also communicate with tone of

voice and facial expressions – Be aware of your body language

Tips for Listening

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• Tips for non-verbal communication – Don’t assume a frown means someone disagrees with you –

they may be thinking really hard – People look to the eyes for how you really think and feel – Your face is one of the most obvious indicators of your attitude

and feelings

Tips for Non-Verbal Communication

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• When communicating with others, it is your responsibility to ensure that the message you send is received and clearly understood.

• You can do this by asking for a repeat back, and follow up with questions to check understanding

Check for Understanding

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• Staff also communicate about where a patient is coming from and is headed to through a Ticket to Ride

• A Ticket to Ride ensures continuous care when

transporting a patient from one department/diagnostic area to another.

• When patients travel between departments they should have a TICKET TO RIDE. – A nurse should initially fill out the Ticket to Ride – The Ticket to Ride has important patient information to keep

patients safe

Ticket to Ride

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• A rapid response (RR) is a way of calling for immediate help for a patient with a deteriorating condition.

• It allows anyone to call for a specialty team to examine a patient at the first sign of decline to initiate immediate interventions that will improve the patient’s outcome.

• The Rapid Response Team (RRT) is a team of ACLS trained clinicians who bring critical care expertise to the patient wherever it is needed. Their response time is within 5 minutes.

Rapid Response

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• Why do we need it? – It can reduce death rates in hospitalized patients. – You may see someone in a bad condition and it is

crucial that you are aware of your ability and responsibility to call a Rapid Response.

– A Rapid Response can help prevent Code Blues! Patients who experience code blues in hospitals often have observable signs 6-8 hours before the arrest occurs Once a patient codes, their survival rate greatly decreases. Early recognition of these signs and quick treatment can

reduce the number of code blues

The Importance of Rapid Response

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• ANYONE can call a rapid response, including: – Family Member – Patient – Any staff member

• All associates, patients, and visitors are required to receive information on how to call a Rapid Response. – The information is located in the patient guide. It is

reviewed with patients and their visitors upon admission.

Who can call a Rapid Response?

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• A Rapid Response/Medical Emergency can only be called when you are at: – One of our 3 hospital locations – St. Lucie West campus

• If you are not in one of these locations, then call 911.

• Do NOT call the house supervisor directly – The emergent situation may not be attended to

immediately because the house supervisor receives a large number of calls.

Calling a Rapid Response

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1. Call the Command Center’s Medical Emergency Line ext. 14444 or 44444

If the phone system is down, (ex: because of a disaster or power failure) use the Beige Emergency Phone (BEP) and dial

221-7738

2. Request a “Rapid Response” to the location (ex: patient room and bed number) 3. Remain with the patient until the Rapid Response Team (RRT) arrives 4. Provide the RRT with any information related to why you called the RR

Steps to Calling a Rapid Response

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• No matter your job role, if you hear an alarm sounding from medical equipment, you have a responsibility to respond.

• Promptly responding to alarms can save lives. • Let your leader/team know if you have any ideas that

could help • Ensure that medical equipment and alarms are heard

Alarms serve a purpose. They notify us that something is wrong,

even though they create noise and can be seen as annoying.

Do NOT ever do the following Disable alarms Disconnect alarms Ignore alarms Silence alarms

Medical Equipment Alarms

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Below is a guide to help you take the correct action every time you hear an alarm.

Responding to Equipment Alarms

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Do you know why the alarm is sounding?

Do you use this equipment to do your job

AND know the appropriate response to

the alarm?

Then you should…

YES YES Respond and address the alarm

NO NO Notify the person in

charge in that area about the alarm

• Did you know that every 60 seconds, a working adult can touch as many as 30 items? That’s 1,800 items per hour!

• Hot zones are areas/items where bacteria and viruses build up. This is because they are the items touched more often.

• The top Hot Zones in Hospitals are: – Door knobs

– Restroom lights

– Computers

– Stethoscopes

– Bedrails

– Telephones

– Keyboards

Beware of Hot Zones

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The green X marks in this picture show areas of risk for hand and glove contamination after contact with a VRE-positive patient.

Contamination

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Hand washing is the #1 way to stop the spread of illness and disease!

Correct hand hygiene reduces transmission of harmful

organisms and reduces overall infection rates.

Hand Washing

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It is our duty to wash our hands to stop the spread of bacteria. There are hand washing requirements to make sure that everyone is properly protecting patients and associates from infection. Hand washing is required before and after:

– Each time you provide patient care- for every patient, every time – Have contact with the patient’s environment – When using gloves for any purpose – Using equipment including computers and telephone – Visiting the bathroom – Transporting a patient – Preparing /serving food – Removing waste or debris

*This Standard Precaution is always warranted for every patient, whether or not on contact isolation.

Hand Washing

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5 Moments for Hand Hygiene

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Soap and Water vs. Alcohol-based Hand Sanitizer

Use soap and water to wash:

• When hands are visibly soiled

• After handling – Infectious materials (such as

blood or body fluids) – Patients with diarrhea

• When preparing and handling food

Use an alcohol-based hand sanitizer:

• Before direct patient contact • After contact with

– Patient’s skin – Body fluids – Wounds – Broken skin – Equipment or furniture near

patient

• After removing gloves

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Kill/Dwell time is the amount of time a surface must remain wet for a product to effectively kill all micro-organisms present.

Kill/Dwell Times for Cleaning Wipes

Use First Wipe

Used on surfaces and objects to thoroughly clean off •Heavy soil •Blood •Bodily fluid from surfaces or objects, if present.

Additional Wipes

Used to disinfect •Make sure to use appropriate kill time and friction.

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*C. Diff is an extremely dangerous and infectious bacteria.

Top Kill/Dwell Time

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Hand Washing and Gloves – Gloves only reduce

contamination and bacterial transmission by 70-80%

– If you wear gloves, you still must wash your hands after removing the gloves.

Gloves

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Use gloves when touching: – Blood – Body fluids – Secretions – Excretions – Contaminated items – Mucous membranes – Non-intact skin

*This is a Standard Precaution and is always warranted for every patient, whether or not on contact isolation.

Gloves

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Mask/eye protection is required when procedures and/or activities are likely to produce splashes or sprays of blood and/or bodily fluids.

• Protects:

– Eyes – Nose – Mouth

*This is a Standard Precautions and is always warranted for every patient, whether or not on contact isolation.

Mask/Eye Protection

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Gowns are required when procedures and/or activities are likely to produce splashes.

• Protects

– Skin – Clothing

*This is a Standard Precautions and is always warranted for every patient, whether or not on contact isolation.

Gowns

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• Follow isolation policy to prevent transmission of micro-organisms between patients

• Isolation signs are used to tell what type of personal protective equipment is required and what precautions need to be taken when entering a patient’s room. Below are some examples.

Isolation

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Sign Color Isolation Type Required Personal Protective Equipment

Red* Contact Isolation • Gown • Gloves

Orange* Contact Isolation

Used for C. diff **only • Gowns • Gloves • Strict hand washing with soap and water only, Purell gel is not effective

against C. diff spores • Bleach cleaning only with Orange top wipes

Blue Airborne • Gown • Gloves • N95 mask

Green Neutropenic • Gown • Gloves • Surgical mask

Lime Green Contact/ Droplet

• Gown • Gloves • Surgical mask

Isolation Sign Color

*Red and Orange signs are often interchanged because both are contact isolation, but it is important to not interchange them to prevent cross contamination due to incorrect hand hygiene and cleaning after patient contact. Think Cdiff…Orange wipes, orange sign. **C. Diff is an extremely dangerous and infectious bacteria.

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• Flu (Influenza) is – Very contagious – A respiratory disease – Can cause serious complications,

hospitalization, or death • How is it spread?

– By droplets from coughing and sneezing – By touching contaminated surfaces

• Do NOT come to work if you are exhibiting flu like symptoms

What is the Flu?

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• You are required to: – Get a Flu Vaccine annually You will get an identifier for

your ID badge OR

– Sign a Waiver to not get the Flu Vaccine You must wear a mask in all patient care areas

• How to get your vaccine: – Get your flu shot annually as soon as it is available (usually

August or September). – Occupational Health will give you a free flu shot at this

time.

Getting Your Flu Vaccine

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• Examples of suicide risk factors include: – Previously attempted suicide – Suicidal thoughts or behaviors – Family history of suicide or psychiatric illness – Currently taking antidepressants – Physical health problems, delirium or dementia,

chronic or acute pain with poor prognosis – Social stressors (ex: divorce, financial,

employment or relationship)

Suicide Risk Factors

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Suicide warning signs include: – Irritability, Anxiety, Agitation, Impulsivity – Decreased emotional reactivity – Unrelenting pain – Crying spells – Declining medications – Request of early discharge – Hopelessness or helplessness – Decreased interest in treatment or prognosis – Feelings of worthlessness – Refusal to eat

Suicide Warning Signs

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• Ensure the suicidal patients have appropriate safety precautions in place – Sitter – Personal items removed – Ligature assessment performed and risks

mitigated

Suicide Precautions

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• Pay attention to patients, associates, and visitors. If you feel someone is a suicide risk, then stay with them and call Command Center (ext. 15741). – Notify the nurse if applicable – RNs need to complete the Suicide Risk

Assessment on Epic.

Is Someone a Suicide Risk? Contact Information: → Command Center at ext.

15741 → Suicide Risk Policy

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• Falls can lead to more injuries or be fatal; however,

patient falls can be preventable. • We want to heal people who come into our facilities, not cause them more injuries.

– RNs need to fill out the Fall Risk Assessment using the Hendrich Fall Assessment tool which identifies those at risk every shift and after any falls or changes in their condition.

– Interventions may include the use of sitters at the bedside or telesitters.

• Move tripping hazards out of the way and be alert for signs that indicate that a patient is a fall risk.

Patient Falls

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• To identify patients that are a fall risk, look for: – Signs over patient bed – Yellow:

“fall risk” patient armbands light over room door slipper socks

• Listen for bed and chair alerts – Respond as quickly as possible

• Patients travel throughout the hospital. These identifiers are a great visual and auditory indication that these people are at risk. – For example, if you see someone with yellow slipper

socks going down the hallway by themselves, then you know that they are at an increased risk for falling. In such a situation you should call for assistance and stay with the patient until assistance arrives.

Identify Patients that are a Fall Risk

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Types of Abuse and Vulnerable groups

Abuse can be:

• Physical • Psychological or Emotional • Sexual • Neglect • Financial

Who might be abused? • Children • Adults • Disabled • Patients • Co-workers • Friends • Family • …anyone

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Signs of Abuse

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Signs of Abuse • Poor eye contact • Wary of physical contact • Unusually quiet, withdrawn or tearful • Hesitant to discuss nature or circumstances of injury • Unusual nervousness, anxiety , self-blaming, or feelings of being undeserving • Patient’s spouse/caregiver being reluctant to allow the patient to be interviewed alone • Fear of a particular person • Seems withdrawn or depressed • Sudden weight change • Shy away from physical contact • Ran away from home • Unexplained bruises • Unusual burn • Head injuries in very young infants/children • Head or facial injuries, black eye, bruised cheek bones, suspicious marks on throat • Abdominal injuries • Suspicious fractures

Examples of neglect include: – Not providing adequate Nutrition Hygiene Clothing Shelter Access to necessary health care

– Failing to prevent exposure to unsafe activities and environments.

Examples of Neglect

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If you suspect immediate danger: Call Command Center ext. 15741 (or 911 if you are not at one of the main hospitals)

Non-Clinical Associates

– If you see a person (patient, associate, visitor, etc.) who shows signs of abuse or neglect, then communicate your concerns either to your leader or the person in charge of the area.

Clinical Associates

– If you admit, examine, or treat people then you must report any actual or suspected case of abuse of a child, elderly person, or disabled person. You must report to the Department of Children and Families Abuse Registry (1-800-962-2873) or online at https://reportabuse.dcf.state.fl.us/. Reports can be made 24 hours a day, 7 days a week.

– The FIRST Clinical Associate to encounter the alleged abuse or neglect has the obligation to report the abuse

– Note: All records concerning reports of abuse are confidential. You are required to include your name in the report. The name of the reporter is kept confidential by the Department, unless you consent to the release in writing. Florida law allows the phone conversation to be recorded.

– FAILURE TO COMPLY WITH REPORTING REQUIREMENTS MAY RESULT IN STATUTORY PENALTIES BEING IMPOSED.

Your Responsibility to Act

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• To provide the best service to our patients and their families it is important that every person understands the procedure and medical care plan which has been agreed for them every time. Understanding is often a challenge when their first language is not English.

• To be our best we want to communicate to the patient and family in the language they prefer.

• Our policy and procedure is to use a Language Line at (800-643-2255, client ID #203019). We use this line always to ensure a reliable interpretation from healthcare professionals.

• We DO NOT use staff to interpret for patients as this is at risk of being unreliable.

• The line can be called 24/7 Please ensure it is used for every person , every time that it is needed. It will avoid the risk of inaccurate translation and confusion for the patient and their families.

Interpreters Contact Information: → Language Line at (800-

643-2255, client ID #203019)

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Stroke symptoms include sudden changes such as: – Sudden numbness or weakness (especially on one side of the body) of

Face Arm Leg

– Sudden trouble Walking Speaking Understanding Seeing in one or both eyes

– Sudden loss of Balance Coordination

– Sudden dizziness – Sudden confusion – Sudden severe headache with no known cause

Stroke Symptoms

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F Face Drooping

Ask the person to: smile Does one side of the face droop? (If YES then ACT)

A Arm Weakness

Ask the person to: raise both arms Does one arm drift downward?

S Speech Difficulty

Ask the person to: repeat a simple phrase Is their speech strange?

T Time to Call for Help

If YES to any of these signs then IMMEDIATELY call CODE GRAY (ext. 15741) or call 911

Stroke Signs

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If you see someone with any of these signs/symptoms then make a call immediately. Every second counts • Call a Code Gray at ext. 15741 (if you are at

1 of the 3 main hospitals)

• Call 911 (if you are NOT at 1 of the 3 main hospitals)

Time to Call for Help Contact Information: → Command Center at ext.

15741

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• An IT Downtime is a period of time when any software systems are not working as expected to perform key functions to maintain hospital operations – Other terms include Epic Downtime and BCA

(Business Continuity Access) Downtime • Please be prepared by understanding your

departments’ procedures and where to locate them.

IT Downtime

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Patient Information Safety

Module 3

1

• You have the responsibility to protect patient, associate, and organizational information.

• This means following: – HIPAA law – Standards on protected health information – MHS Information Security and Privacy Policy – MHS HIPAA Privacy and Security Policies – MHS Network Access Agreement

• For additional information on keeping protected

health information (PHI) safe, contact – Information Security at ext. 14811 – Corporate Compliance at ext. 11983

Introduction

2

HIPAA includes both the HIPAA Privacy Rule and HIPAA Security Rule. These rules outline National standards for protecting PHI and security standards to protect PHI that is held or transferred electronically. This includes how to keep PHI safe and confidential by taking certain administrative, physical, and technical safeguards.

What is HIPAA and PHI?

3

HIPAA Health Insurance Portability and Accountability Act 1996

PHI Protected Health Information

• It is your responsibility to protect the privacy and security of patient’s Protected Health Information (PHI).

• PHI includes: – Patient identification – Demographic information – Medical record information – The fact that a patient is in the facility

Protected Health Information

4

• Do not access a record if you do not need to for patient care!

• Consequences of inappropriate access include: • Termination

• Legal action

• Written warning

• Counseling / Education

• Any impermissible use or disclosure is presumed to be a breach, unless we can prove there is a low probability of compromise to the PHI.

Consequences of inappropriate access

5

MHS conduct audits of records to look for inappropriate access to files

– Audits of medical record access Can confirm inappropriate access Are done randomly and regularly.

– “High-profile patient” records are routinely

audited for inappropriate access

MHS looks to see if you have looked!

6

• High profile patients include: – Famous people Patients who may attract (or whose families or

significant others may attract) media and/or community interest Local, national, or international

– Traumas Patients with extreme or unusual injury or illness, or

patients whose injury or illness resulted from an extreme or unusual event

– Criminals or protected witnesses

High Profile Patients

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• If you become aware of a high profile patient – Call the Command Center at ext.

15741 so that a Lead Security Officer can be dispatched immediately to that location

High Profile Patients Contact Information: → Command Center at ext.

15741

8

• We want to do what is right and helping law enforcement seems right. However, when it comes to PHI, we cannot just ‘answer’ or ‘release’ information. HIPAA and Florida Law have special requirements that must be respected.

• It is your responsibility to follow policy when Law Enforcement asks for patient information.

If Law Enforcement makes a request: be respectful, but do not be intimidated into disclosure!

Releasing Information to Law Enforcement

9

Situation What to do

If the patient or personal representative has signed a valid authorization.

You CAN release information

If the patient has consented to being listed in Martin Health System (MHS) directory and Law Enforcement requests information on the patient by name, then

Law Enforcement can be told “directory” information (i.e., only patient location and condition in general terms--critical, good, etc.) Law Enforcement cannot be told a time or plan for discharge.

If the patient poses imminent threat to himself or others and the information is needed to avoid harm to the public.

You CAN release information

If Law Enforcement requests information on a patient that is a suspected victim of a reportable offense under Florida Law, including child or vulnerable adult abuse.

Check with Risk Management, Legal, or Compliance on situations

If a Law Enforcement request involves possible criminal conduct occurring at MHS.

Check with Risk Management, Legal, or Compliance on situations

If a patient is a suspected victim in a crime Information can be released if the patient signs a valid authorization

Example Situations

If a patient is not “in custody” of Law Enforcement, information can only be released in certain situations

10

• Privacy incidents include patient information • Do not access or send a record if you do not

need to for your job! • Consequences of inappropriate access or use

of PHI: • Termination

• Legal action

• Written warning

• Counseling / education

Privacy Incidents and PHI

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• You are accountable for the privacy and security of patient information

• Associates are required to follow HIPAA

• Associates are required to understand and follow MHS’s: – HIPAA Privacy and Security Policies – Network Access Agreement

Your Responsibilities

12

PHI and Personal Identifiers

• Contact Information – Names

– Street address, city, county, precinct, zip code

– E-mail addresses

– Telephone numbers

– Fax numbers

• Other personal information – Social Security number

– Medical record numbers

– Account numbers

– Certificate/license numbers

– Biometric identifiers, including finger and voice prints

– Health plan beneficiary numbers

– Full-face photographic images and any comparable images

• All elements of dates (except year) – Birth date

– Admission date

– Discharge date

– Date of death

– Ages over 89

• Electronic Device and Internet Information – Device identifiers and serial numbers

– Website addresses (URLs)

– Internet Protocol (IP) addresses

• Vehicle information – Serial numbers

– License plate number

– Other vehicle identifier

• Any other unique identifying number, characteristic or code

You must keep this information private because it can identify patients!

13

• Be aware of your surroundings when discussing patients and sharing PHI. Think about: – Who is around you? – What you are sharing? – Where are you? – When are you sharing?

• If you obtain a patient’s verbal authorization to disclose PHI, be sure to document the authorization in the patient’s electronic medical record (EPIC).

• Review information prior to release to be sure you are giving it to the correct patient or authorized person.

Be careful when dealing with PHI and Personal Identifiers

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• Information is de-identified if: – All of the identifiers (listed on the PHI and Personal

Identifiers slide) of the individual or of relatives, employers, or household members of the individual are removed.

AND – The covered entity* does not have actual knowledge

that the information could be used alone or in combination with other information to identify an individual who is a subject of the information.

*Covered entities are defined in the HIPAA rules as (1) health plans, (2) health care clearinghouses, and (3) health care providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards.

De-identified Information

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• Slow down and verify recipients and content. • Before you share information, verify:

– Identities – Phone number(s) – Fax number(s) – E-mail recipient(s) – Correct attachment(s)

Confirm Before Sharing and Sending

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• Don’t leave printers or faxes unattended when confidential corporate or patient data is printing.

• Secure interoffice mail • Dispose / shred in accordance with policies

Proper Management of Documents

17

• Check ALL papers before handing to a patient • Use TWO patient identifiers to confirm you

are handing to the correct patient – Name – Date of Birth – Use the 2 step method

1. Ask patient to confirm the 2 identifiers 2. Check their arm band

How to Prevent: Paperwork Handoff Errors

18

Do NOT access records (electronic or paper) not needed to do your job. Records that you should NOT access include:

– Records of patient not in your care – Records of a friend, family, or fellow

associate (even if they ask) – Your own medical record

Instead use: My Chart or request your records through Health Information Management Team (HIM)

No! Do Not Access

I’d like to help. But you really need to

call HIM. They’ll get your information.

19

It is OKAY to access information that you need to do your job, such as for

– Patient treatment

– Patient scheduling

– Coding a patient chart

– Admitting a patient

– Obtaining authorization for treatment

Yes! Okay to Access

20

Accessing a medical record not for treatment, payment, or healthcare operations purposes is inappropriate. But what is included in the “medical record”? A patient’s medical record includes: • Treatment information • Demographic information • Scheduling and appointments

Accessing any portion of a patient’s information, unless needed for work, is inappropriate.

A note on “medical record”

21

• This is a Special Privacy Setting in EPIC that Triggers an Audit Trail.( EPIC is our Clinical Information System, certain job roles have access)

• If you have a “need to know” to do your job, follow the instructions to “break the glass” and proceed. You are asked to give your reason for needing to be in the record and identify your entry once in a 24-hour period.

• If you do not need to be in the record, do not enter it. The automatic audit helps keep our patients’ information private, and also protects us from momentary lapses in judgment and accidental intrusion into sensitive matters.

“Break the Glass”

22

• If you do not need the information to do your job…then do NOT access it!

• Notify your leader if you have access to more information than you need on your computer.

Unauthorized Access

23

Remember: – You are held accountable for unauthorized access

of information. This is outlined through procedures within: HIPAA ( Law) MHS Policy MHS Access Agreement

– We run audits routinely to identify unauthorized access, taking our corporate responsibility to protect patient information.

Unauthorized Access

24

• Be aware of surroundings when discussing patients and sharing PHI. Think about – Who is around you? – What you are sharing? – Where are you? – When are you sharing?

• Verify identities and phone numbers prior to disclosures

Be Aware when Sharing PHI

25

• Remember…the world sees what you post – Represent MHS as a professional – Protect patient and MHS information and

privacy • PHI and personal identifiers can come out

easily in an innocent post. • Think before you tweet or post!

The Dangers of Social Media

26

Jamie Jones

Works at: Martin Health System

June 15, 2016 “We were outstanding today!”

Sam Miller

Works at: Martin Health System

June 15, 2016 “I don’t know how you all did it!”

Jamie Jones

Works at: Martin Health System

June 15, 2016 “It was like an episode of Grey’s Anatomy.”

Sam Miller

Works at: Martin Health System

June 15, 2016 “Without the Dr. McDreamy...”

Jamie Jones

Works at: Martin Health System

June 15, 2016 “But we had Dr. Yang to crack the guy’s chest!”

Example of Social Media in Use

27

• From this chat, you can tell that – This happened at Martin Health System

– On June 15, 2016

• If there was a patient who got his chest “cracked,” this conversation went too far! This conversation has identifiable health information!

Discussion About Example

28

• And it could easily be worse. Suppose someone else commented and – Added a piece of PHI? – Referred to a news story with information?

• If this happened, you would be faced with consequences for being a part of a privacy breach.

Play it safe. Do not risk it.

Do you want to be the associate who needs to worry and explain? Compliance does not want that either.

Discussion About Example

29

• You could: – Be terminated – Be fined – Face legal consequences

Consequences of Posting

30

Consequences of Posting: Examples

31

Situation Consequence Several Employees here at MHS took pictures of a shark attack victim. Employees involved received written warnings, demotions,

and/or suspensions.

A Rhode Island ER doctor posted information online about a trauma patient. The doctor did not include the patient’s name, but she wrote enough that others in the community could identify the patient. (Boston Globe, April 2011)

The doctor was fired, fined $500, and reprimanded by the Rhode Island Medical Board.

At a medical center in Oceanside, hospital managers discovered that five nurses had been discussing patients on Facebook.

The five nurses were fired.

The Phoenix Cardiac Surgery of Arizona was posting clinical and surgical appointments for its patients on an internet-based calendar that was publicly accessible. (HHS, April 2012)

The practice agreed to pay the U.S. Department of Health and Human Services a $100,000 settlement and take corrective action to implement policies and procedures to safeguard PHI of its patients .

Follow the MHS Computer Network Access Agreement and MHS HIPAA Privacy and Security Policies. For additional guidance, contact Information Security (ext. 14811) or Corporate Compliance (ext. 11983). If unavailable, you can also contact Command Center (ext. 15741).

Information Security

32

Contact Information: → Information Security at

ext. 14811 → Corporate Compliance at

ext. 11983 → Command Center at ext.

15741

• Make an effort to obscure PHI from public view on monitors and papers at your station.

• Lock your computer or log off if you need to walk away • Do not add, delete or change software without IT approval • Do not send PHI via email. It is like a postcard…anyone

could turn it over and read it along the way. • If you need to send PHI via email, enter [secure] anywhere

in the subject line. This encrypts the message through a process set up by our IT department.

• Verify identities, fax, and phone numbers prior to disclosures

Ways to Protect Information Security

33

• Patient Information – Never take reports or computer media that contain patient

information outside of your workplace. • Other Confidential Information

– Taking or accessing associate and organizational information outside of the workplace increases the risk of a security breach.

– Protect paper documents, USB drives, and laptops. If information is taken outside of the workplace, make sure to secure

the information in a locked area. Leaving items in a car increases risk because it can easily be broken

into. – Protect information accessed electronically.

If you access information electronically, make sure to use a proper device with security protection.

Taking Information Outside of the Workplace

34

Physical Safety

Module 4

1

Need Call

Security / Police at our hospital campuses

Command Center ext. 15741 223-5741

Medical Emergency at one of our hospitals

ext. 14444 or 44444

Police or Medical Emergency off sites

911

Numbers to Call in an Emergency

Note: If you call from an internal Martin Health extension number, then your call will be routed to the Command Center. The Command Center will conference in

the 911 operator.

2

Emergency Codes Call Command Center at ext. 15741 Code BLACK Bomb Threat

Code BLUE Medical Emergency

Code Yellow Facility Lockdown

Code GRAY Stroke Alert

Code GREEN Medical Surge/External Disaster

Code ORANGE Hazardous Materials Event

Code PINK Infant/Child Abduction

Code RED Fire

Code SILVER Active Shooter

Code WHITE Hostage Situation

Code H2O Water Service Disruption

Emergency Codes Contact Information: → Command Center at

ext. 15741

3

Code Purple Patient Elopement

• Never stack anything within 18 inches of a sprinkler head, so be careful when placing items on shelves and organizing furniture

• Never block the following with furniture, supplies etc. There must be clear space around every: – Fire exit- doors are clearly marked as a fire exit

– Fire pull station

– Fire extinguisher

Fire Safety

4

• Know the location nearest – Smoke compartment – Fire extinguisher – Fire pull station – Fire exit

• Limit oxygen cylinders in a smoke compartment to 12

• Keep hallways clear in case of evacuation

Fire Safety

5

Parts of a Fire Extinguisher

Discharge Lever

Discharge Locking Pin

Discharge Hose

6

P Pull the discharge locking pin

A Aim the discharge nozzle at the base of the fire

S Squeeze the discharge lever

S Sweep the flames at the base of the fire with the discharge hose

How to Use a Fire Extinguisher

Discharge Lever

Discharge Locking Pin

Discharge Hose

7

R Rescue

A Alarm

C Confine

E Extinguish

If There Is A Fire (North, South, Surgery Center, SLW, Tradition)

8

R Rescue

A Alarm

E Exit or Extinguish

If There Is A Fire (All Other Sites)

9

• Enforcing proper identification and controlling who accesses different areas of MHS is your responsibility.

• The following lesson will outline badge and access control policies. By following these policies, you will help – Decrease theft – Decrease access by unauthorized visitors and vendors – Increase safety and security

Identification and Access

10

• Everyone must be visibly identified – Associates – Vendors – Visitors

• Wear your badge above your waist

Badges

11

Main entrance Do direct visitors, guests, patients, and vendors

to enter through the main entrance of the facility where a security officer can verify identification.

Secured associate entrances X Do NOT allow visitors, patients or guests to enter

through a secured associate entrance (instead direct them to the main entrance)

Access Control

12

• If it is an emergency and the person cannot get to an appropriate entrance, it is the associate’s responsibility to escort the person to the nearest security post for assistance.

• If you are at an off-site clinics/business office, then escort patients and visitors to the building’s entrance.

Access Control in an Emergency

13

Type Examples If These Items are Lost or Found

Valuables

• jewelry • credit/debit cards • check book • money • personal IDs such as driver’s license or social security

card

Call Command Center ext. 15741

Essential Items

• hearing aids • glasses • dentures • prostheses • assistive devices such as walkers or canes

Personal Belongings

• medications • clothing, shoes • umbrellas • electric razors • hair dryers • cell phones • radios

Lost/Found Items

14

If you have a work-related injury, illness, or exposure:

1. Notify your leader at once

1. In case of emergency, go to your nearest emergency room.

2. If after 5pm or weekend/holiday: Call the hospital operator and ask for the on-duty nursing supervisor to help you coordinate your care. Follow up with Occupational Health, ext. 14812, the next business day.

3. Contact Occupational Health at 223-5945, ext. 14812 immediately to help coordinate your care.

Note: • Treatment must be authorized by Occupational Health. • Call Occupational Health for follow up at x14812 • All injuries must be reported. Failure to report your injury timely could jeopardize your

benefits.

In Case of Workplace Injury or Blood/Body Fluid Exposure

15

• The Globally Harmonized System (GHS) replaces the old Material Safety Data Sheets (MSDS).

• Using GHS will improve work safety and health by:

– Reducing confusion regarding MSDS – Providing consistent information – Providing a standardized format for hazardous chemicals

Globally Harmonized System (GHS)

16

• GHS covers – ALL chemicals – Uses standardized pictograms and harmonized hazard statements

in the workplace on consumer products (transportation changes are not expected to follow these new guidelines)

• The pictograms for non-transport have a – red- border – white background – black symbol – information is in the same place on all labels

• The word “Danger” is used for more severe hazards • The word “Warning” is used for less severe hazards

Globally Harmonized System (GHS)

17

GHS Pictograms

These are the different GHS Pictograms.

18

GHS Label Elements

19

• Your safety is extremely important. Be careful when doing something where you can get injured or be exposed to biomedical material. Personal Protective Equipment (PPE) is a requirement to help protect you from injury or exposure. You are required to use PPE* when there is an actual or potential exposure to:

– Blood

– Body fluids

– Other regulated or biomedical items

• Handle materials carefully and dispose of them correctly! – Dangerous diseases can be spread if you do not take proper precautions. For example,

be careful with sharps because HIV, Hepatitis B or C, and other viruses can be spread via needle sticks.

*Refer back to ‘Module 2: Patient Safety’ to review information related to personal protective equipment.

Biomedical Exposure

20

• Make the correct disposal decision. This will protect your health and the health of people who handle the waste after you.

Biomedical Waste

21

• Biomedical waste is any solid or liquid waste which may present a threat of infection to humans, including: – Non-liquid tissue – Body parts – Blood – Blood products and body fluids – Discarded sharps

Biomedical Waste

22

How to Dispose of: Biomedical Waste

Red Bag: Things saturated with

blood or body fluid

Red Box: Needles Scissors Scalpels

(NO non-sharps!)

Potential Sharps Box: Anything that could

become sharp

23

Proper Tying of Red Bags – While wearing gloves, twist the

top of the bag to seal its contents. Secure the seal with a strong, hand-tied single or gooseneck knot to prevent any leakage if inverted. You can also use tape to secure the knot. Ensure that the bag is completely closed; No Bunny Ears!

How to Dispose of: Biomedical Waste

24

• Common examples of UPW are: – IV formulations with additives – Partial vials or syringes of antibiotics – Medications – Creams – Lotions – Ointments – Inhalants

Universal Pharmaceutical Waste (UPW)

25

• Use the black boxes to dispose of any Universal Pharmaceutical Waste (UPW), which are “non-viable, partially-used” pharmaceuticals – This helps to achieve environmental compliance

and to improve water quality

• Please keep the black box closed when not adding UPW items to it

How to Dispose of: UPW

26

Medical Center and Hospital South All other sites Medications left in a sharp Includes

• Syringe (with meds) • Ampoules (with meds)

*No empty items, trash, etc… *No controlled substances or plain IV solutions

All UPWs Disposable Containers

Medications left in non-sharp format Includes

• Partial IV bags/vials • Pills/capsules • Medicated creams • Nicotine, Coumadin, & Physostigmine wrappers

*No empty IVs, trash, gloves, etc. *No controlled substances or plain IV solutions

Send to Pharmacy in Ziploc bag Includes

• All items with “return to pharmacy” stickers • Aerosols/Inhalers • Corrosives/Oxidizers

How to Dispose of: UPW

27

• Red Outlets – Are connected to the generator – Will have power in the event of an electric failure – Are only for critical patient care equipment (plug

patient beds into “bed only” outlets)

Outlets

28

• Do NOT use damaged or frayed electric cords. Take them out of service and report them to your supervisor to get fixed

• Only use 3-progned plugs in clinical areas • You must have bio-med approval for

– Extension cords – Electrical devices

• Check for green bio-med sticker before using clinical equipment

Electrical Safety

29

Keep in mind the following 3 rules to help improve radiation safety

Time Shielding Distance Limit exposure time

Use all required shielding items

Hazard decreases with distance from the

source of the radiation

3 Rules to Improve Radiation Safety

30

• If you routinely work with or near radiation sources – You are required to wear a dosimeter that measures exposure – If you are also pregnant you should declare your pregnancy to

you supervisor for assessment

• Rooms where radiation is used or stored are identified with the universal radioactive materials symbol (shown below).

• Specially trained Radiation Safety Officers are employed by MHS to ensure safe working conditions for associates working with or near radiation sources

Radiation Safety

31

• When working with chemicals – Follow all labeling instructions – Use personal protective equipment as applicable – Make sure you are in a well-ventilated location

(proper ventilation is required the majority of the time)

• When mixing chemicals – Make sure the chemicals are supposed to be mixed – Make sure to use the right concentrations of the

chemicals

Chemical Safety

32

• The most common gas that is handled is in oxygen cylinders

• Simple safety rules:

– Separate full vs. empty cylinders – Store upright when possible and only in approved holders or racks – If chained to a wall, make sure they are individually chained – Transport cylinders in approved holders only – Make sure cylinders won’t fall over, or fall off a bed or stretcher – Never have more than 12 e-size cylinders in a smoke

compartment

• A cylinder can quickly become a fast moving missile if it falls. Prevent damage, injury, and death by properly storing and securing cylinders.

Gas Safety

33

Knowing MRI safety is important for everyone that: – Has access to the MRI department – Has a patient who will be going to the MRI department

MRI Safety

34

Access to the MRI scan room is – Only allowed for highly trained MRI staff – Only permitted when accompanied by MRI staff – NEVER enter into the MRI scan room without

consulting the MRI technologists.

The Magnetic Field is ALWAYS on!

35

It is extremely important that you receive proper training and screening before entering an MRI area! If you enter an MRI area with no/poor training, then you could cause extreme injury or death to the patient or fellow associates.

MRI Deadly Dangers

36

• Ferro-Magnetic objects WILL become potentially deadly missiles. – Examples include:

O2 tanks Wheelchairs Beds Monitors IV poles Scissors Pens Tools ID badge holders

– Once an object attaches to the magnet, it will not come off. It will cause significant cost and down time.

• Not all MRI accidents involve projectiles. Some patients and staff have implanted devices that they need in order to function or even live.

– Pacemakers / defibrillator – Nerve or bone stimulators – Medication pumps – Aneurism clips and any surgical implants or foreign bodies

Dangerous Items to have in MRI Scan Rooms

37

• Call MRI at ext. 11111 for further information and questions about MRI Safety

MRI Information Contact: → MRI at ext. 11111

38

• Ball-in-the-Wall indicators – Are visual pressure indicator of room air pressure

– Have been installed in rooms with regulated air pressure

• View the Ball-in-the-Wall from the hall outside the room

• A room’s air pressure can only be regulated when the doors are closed

Ball-in-the-Wall

39

• The ball-in-the-wall is a small tube that goes between the inside and outside of a room.

• There is a ball inside of the tube that moves from one side to the other depending on the pressure in the room.

• If you are standing in the hall and see a ball, then – The ball is being pushed out of the room. This indicates

that the room has positive air pressure pushing germs out • If you are standing in the hall do not see a ball, then

– The room has negative air pressure and is not allowing the germs into the hall

How it works

40

Positive Rooms Negative Rooms

These rooms… Push airflow and germs out of the room

Pull airflow into the room so that germs are not getting into the hall

Examples

Only applies to OR rooms at 509 building (ORs in the hospitals are monitored by Siemens computer-

monitored DP system)

Such as isolation rooms

Look at the ball-in-the-wall from the outside of the room with the door

closed. Things are okay if you see…

Green ball No ball

Look at the ball-in-the-wall from the outside of the room with the door

closed. Something is wrong if you see…

No ball Red ball

If you see a no ball—STOP and call Facilities Engineering to correct

If you see a red ball—STOP and call Facilities Engineering to correct

Ball-in-the-Wall

41

• Every day you should make sure that you are: – Using the proper personal protective equipment

– Taking breaks from sitting and staring at a screen

– Staying hydrated

Maintain Health and Safety at Work

42

MHS workplace injury prevention resources for associates

• To prevent falls, order your discounted, slip-resistant shoes Shoes for Crews by credit card or payroll deduct

• To avoid sprains/strains at your workstation or worksite, request an ergonomic evaluation Ergonomic Evaluation Request

• Watch videos that show you how to safely use patient lifting equipment and butterfly needles Safety Videos

• To find information on working if you have an infection, visit the Infectious Disease Exposure Work Restrictions guidelines

• Learn how to manage aggressive behavior and avoid injury by taking the MOAB course in iLearn

Maintain Health and Safety at Work

43

• For any heavy lifting, use lift equipment and obtain help!

• Direct Patient Care: – Always assess patients prior to ambulation and transfer. Use the Egress Test to determine if

the Arjo Maxi Move, Sit-to-Stand device, or Sara Stedy (TMC) is required.

– Never manually lift a patient who has fallen to the floor. Use the Arjo Maxi Move!

– Always use a Pink Slip for boosting patients up in bed.

– Use the Arjo Tenor for transferring bariatric patients.

– Practice the ten safety rules to avoid sharps injuries and exposure to blood and body fluids Ten Sharps Safety Rules (Printable Cards)

– Wear eye protection when flushing or irrigating patient tubing or whenever there is risk of blood or body fluid splashes

Give us your safety suggestions! Call or email Sandy Rogers, Ext 15454

More Ways to Stay Safe in the Workplace

44

• You should feel safe at work. • Workplace violence is NOT okay. • If you feel threatened or at risk, call

the Command Center at ext. 15741 • The MHS Code of Conduct outlines

this topic

Feeling Safe at Work Contact Information: → Command Center at ext.

15741

45

• Violence can be – Verbal and/or physical – Minor or extreme – Committed by anyone (ex: Fellow associates, Patients, Visitors)

– Directed towards anyone

Violence

46

Examples of unacceptable behavior include: – Physical assault – Sexual misconduct – Threating words or actions – Ignoring or shunning another person/group

Unacceptable Behavior

47

• Sexual misconduct such as sexual abuse or harassment of any kind is unacceptable. Organizational consequences can include termination and legal consequences can include arrest.

• Sexual acts of any kind are unacceptable while on the job or on MHS

property. Additionally, any sexual acts without consent or sexual acts on a vulnerable person (ex: minor or vulnerable adult) are never okay. Sexual acts include, but are not limited to – Touching sexual organs (clothed or unclothed) – Exposure of sexual organs

Sexual Misconduct

48

• Sexual abuse or harassment is forbidden. This includes:-

– Unwelcome or offensive sexual comments, sexual advances, requests for

sexual favors, or other verbal or physical conduct of a sexual nature. – Unwelcome or forcefully touching someone, such as on someone's inner

thigh, breast, genitalia, buttocks, etc. – The use of someone else to solicit for or engage in prostitution or sexual

performance – Rape – The exchange of sexual favors for beneficial employment conditions, – Verbal or non-verbal behavior which contributes to a hostile or offensive work

environment. This may include, but is not limited to, offensive or unwelcome sexual flirtations, advances or propositions; verbal abuse of a sexual nature; graphic verbal commentaries about an individual’s body; sexually degrading words used to describe an individual; and the display in the workplace of sexually suggestive objects or pictures.

Sexual Misconduct

49

• MHS has zero tolerance for any threats to the safety and security of our associates, patients and others at our facilities

• Immediately report any actual or potential threats to – Command Center at ext. 15741 – And to your Leader or Human Resources

(Associate Helpline ext. 12222) • If you have a conflict with a coworker

– contact your leader for guidance with conflict resolution

Policy and Procedure for Workplace Violence

Contact information: → Command Center at ext.

15741 → Associate Helpline ext.

12222

50

• The signs of impaired behavior varies depending on the substance used, but the following are some different things that may indicate an issue.

• Things that might indicate that someone is impaired – Unable to walk straight – Unable to remain balanced while standing or sitting – Speech that is excessively loud, quiet, or slurred – Mood and behavior changes such as being hostile, confused, erratic, or excessively sleepy. – Eyes that are bloodshot or dilated – Breath that smells of alcohol or the attempt to cover up the smell with excessive use of mints,

mouthwash, or perfume – Movements that are fumbling, jerky, slow, nervous, or hyperactive

• Other warning signs – The individual comes to work on their time off and may linger around where drugs are

supplied – Disappears while on duty and/or takes frequent bathroom breaks – Increased or unexplained absence or lateness to work

Signs

51

If you suspect impaired behavior… 1. Immediately notify your leader and Human Resources

of suspected Associate impairment – During business hours: call Sibel Miglino ext. 11269 or

Anna Little ext. 12983 – Off shifts: Notify your Leader/Chain of Command and

call the Switchboard Operator and ask them to contact Human Resources

2. Do NOT allow the associate with the suspected impaired behavior to

– Go home – Have anything to drink – Use the restroom

A determination will be made by Human Resources if

an Associate must undergo physical examination/drug and alcohol testing

Impaired Behavior: What to do

52

Contact Information: → Sibel Miglino at ext.

11269 → Anna Little at ext. 12983

Obligation to Report

Module 5

1

Recall that our Vision is “to be an innovative healthcare system nationally recognized for clinical excellence and improving the health and well-being of the communities we serve”. There are laws, regulations, and MHS policies around reporting that you must follow for us to: • Reach our vision • Be a safe environment that effectively addresses incidents • Prevent future incidents or occurrences

You are obligated to report • Misconduct: associate misconduct concerns • Compliance Concerns: failure to comply with laws, regulations, and

department policies • Occurrences: risk events and feedback

Introduction

2

Reporting Options

3

Reporting requirements differ based on the event, concern, urgency, severity, etc. Below are a few notes about reporting. – In general, it is advised to notify your Leader/Chain of Command for advisement

if you are unsure what to do. Unsure how to report? – Your Leader should be able to advise – Risk Management, Corporate Compliance, or Human Resources are also available

to provide guidance on reporting

MHS Reporting Options

4

MHS Reporting Options Leader

Chain of Command

Risk Management Risk Management Department

ext. 15899

Corporate Compliance Corporate Compliance Department

ext. 11983

Chief Compliance Officer ext. 13957

Human Resources Associate Helpline

ext. 12222

Compliance Hotline 1-877-785-0002 or

www.mycompliancereport.com code MMH

Generally, these are the type of reporting topics the following departments handle.

MHS Departments that Handle Reporting

5

Risk Management Corporate Compliance Human Resources For Risk Events • Patient or non-patient safety

events • Patient/visitor

lost/stolen/damaged property • Associate injuries For Feedback • Patient/client complaints • Patient grievances • Compliments • Suggestions

For HIPAA related concerns • any unauthorized access, use or

disclosure of Protected Health Information [PHI])

For concerns related to the Code of Conduct • examples include: Patient Gifts, Conflicts

of Interest, Vendor Relations, Billing and Coding, and False Claims. (see the MHS Code of Conduct for full list of topics).

For any suspected failure to comply with state or federal laws or regulations or MHS policy

For associate conduct concerns

External Reporting Options

6

External Reporting Options The Joint Commission Hopefully this will be your last resort, but if you have a concern that you feel was not adequately addressed, you may file a safety or quality of care concern directly to Joint Commission:

• Print a Quality Incident Report Form from www.jointcommission.org • Email: complaint@jointcommission.org • Fax: (630) 792-5636 • Mail Joint Commission Office of Quality Monitoring, One Renaissance

Blvd., Oakbrook Terrace, IL 60181 • Questions? Call Joint Commission at (800) 994-6610, 8:30 am to 5 pm

central time, weekdays

Agency for Health Care Administration (AHCA)

• Consumer Services Unit PO Box 14000 Tallahassee, FL 33317 • (888) 419-3456 • http://www.ahca.myflorida.com/contact/links.shtml

Associates and patients ALWAYS have the option to report ANY concerns to the following resources. Throughout this module you will be told how to report within MHS, but please remember that these are also options.

In case of an Emergency

If there is an immediate safety or security concern, you should immediately let the relevant people know in-person or via phone… • Your Leader/Chain of Command • Security/Police (Call Command Center at ext. 15741. If offsite, call 911) • Risk Management • Corporate Compliance • Human Resources

7

When unsure, question. When concerned, report.

MHS and the law prohibit retaliation for good-faith reporting.

The Chief Resource Officer will closely examine claims of retaliation to ensure that

legitimate, non-retaliatory reasons motivated any action taken. If retaliation played a influential part in the action taken, then the Chief Executive Officer will take prompt

and appropriate corrective action against the offender.

Non-Retaliation

8

Administrative Policy: Non-Retaliation • You cannot be retaliated against for making a good-faith report

of a compliance concern • Any form of retaliation against an associate who identifies a

perceived problem or concern, in good faith, is strictly prohibited Other references to non-retaliation and reporting in the Associate Handbook • You cannot be retaliated against for

– Voicing a concern regarding legal regulatory issues, policies and procedures, and/or seeks the aid of Human Resources or files a grievance

– Filing a complaint of harassment – Acting in good faith and reporting a real or implied violent behavior – Reporting variances or medical errors

Non-Retaliation

9

All associates have the responsibility to immediately report misconduct. This includes

– Theft – Impaired behavior – Arrests (If you are arrested, you must self-report to MHS within

48 hours of the arrest) – Sexual harassment

MHS is committed to investigating all reports of misconduct. If you need assistance or have questions, contact the Associate Helpline at ext. 12222.

Misconduct

10

Misconduct Reporting

11

Reporting Options for Misconduct

Leader

Chain of Command

Human Resources Sibel Miglino (ext. 11269) or Anna Little (ext. 12983)

Corporate Compliance Department ext. 11983

Chief Compliance Officer ext. 13957

Compliance Hotline 1-877-785-0002 or www.mycompliancereport.com (code: MMH)

Recall from Module 4: • Immediately report any actual or

potential threats to – Command Center at ext. 15741

– And to your Leader or Human Resources (Associate Helpline ext. 12222)

Reporting Workplace Violence Contact information: → Command Center at ext.

15741 → Associate Helpline ext.

12222

12

Recall from Module 4: If you suspect impaired behavior… 1. Immediately notify your leader and Human Resources of

suspected Associate impairment – During business hours: call Sibel Miglino ext. 11269 or Anna

Little ext. 12983 – Off shifts: Notify your Leader/Chain of Command and call the

Switchboard Operator and ask them to contact Human Resources

2. Do NOT allow the associate with the suspected impaired behavior to

– Go home – Have anything to drink – Use the restroom

A determination will be made by Human Resources if an

Associate must undergo physical examination/drug and alcohol testing

Reporting Impaired Behavior

13

Contact Information: → Sibel Miglino at ext.

11269 → Anna Little at ext. 12983

A Compliance Concern includes: – HIPAA violations: any unauthorized access, use or

disclosure of Protected Health Information (PHI) – Violations of the MHS Code of Conduct: examples

include Patient Gifts, Conflicts of Interest, Vendor Relations, Billing and Coding, and False Claims (see the MHS Code of Conduct for full list of topics)

– Any suspected failure to comply with state or federal laws or regulations or MHS policy

What is a Compliance Concern?

14

• Per our Code of Conduct, associates have an obligation to report suspected failure to comply with laws, regulations, and department policies.

• Failure to report compliance violations will result in disciplinary action.

• If something is troubling you, please call—it’s the right thing to do.

Your Obligation to Report

15

• All Associates have the responsibility to immediately report any suspected violations of regulations, laws, or MHS policy.

• MHS is committed to investigating all reports of violations. • If you need assistance or have questions, contact your leader

or chain of command. You can also reach out to Corporate Compliance directly who will either answer your questions or direct you to the correct person/department.

Reporting Violations

16

Corporate Compliance Corporate Compliance Department ext. 11983

Chief Compliance Officer ext. 13957

• MHS will apply consequences to associates and medical staff for failure to comply with

HIPAA MHS Privacy and Security Policies

• Failure to comply with HIPAA – Information on Corrective Actions and consequences for

non-compliance can be found in MHS HIPAA Privacy Policy HIPAA Privacy Policy #29: Corrective Actions

– Procedures for applying corrective action

HIPAA Privacy Policy #29.A: Privacy and/or Security Incident Matrix

– Categories of violations, examples of violations, and possible consequences that may result

– These sanctions range from verbal warning to termination depending on the severity of the violation.

– HIPAA violations can have criminal or civil penalties

Consequences for Non-Compliance

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• Other consequences for failure to comply with HIPAA and other laws and regulations can include: – Criminal and Civil charges – Notification to licensing boards MHS may be required to report the incident to the

associate’s licensing board for unprofessional conduct. For example, the Nurse Practitioner Act includes

unprofessional conduct as grounds for disciplinary action. Unprofessional Conduct is defined, in part, by Florida Administrative Code – 649B as “Violating the confidentiality of information or knowledge concerning a patient”.

Consequences for Non-Compliance

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How to Report Compliance Concerns

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Reporting Options for Compliance Concerns

Leader

Chain of Command

Corporate Compliance Department ext. 11983

Chief Compliance Officer ext. 13957

Compliance Hotline 1-877-785-0002

or www.mycompliancereport.com (code: MMH)

Department of Health and Human Services (HHS) at www.hhs.gov

Office of Inspector General (OIG) at 1-800-HHS-TIPS

• Use the hotline to report compliance issues if you do not feel comfortable, cannot, or do not want to report something up your chain of command.

• The hotline is – Available 24/7 – Anonymous, if you want – For feedback and follow-

up

Using the Compliance Hotline

Compliance Hotline By phone at:

1-877-785-0002

On the web at: www.mycompliancereport.com

use code: MMH

*You can be anonymous

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• Recall Module 3: Information Safety about HIPAA and Protected Health Information policies

• HIPAA violations are handled by Corporate Compliance.

HIPAA Violations

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Violations of a Patients’ HIPAA Rights can be reported like any other compliance concern.

Accidental accesses and information slips happen. Report if you accidentally disclose Protected Health Information (PHI) OR if you receive PHI (ex: via email) that you should not have received. • You must immediately report

– Unauthorized disclosure of PHI (intentional or accidental) – Any patient complaint regarding the use or disclosure of PHI

• Let Compliance know so they can – Help manage the situation – Understand what we find on an audit

Self-Reporting of HIPAA Violations

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Violations of a Patient’s HIPAA Rights can be reported like any other compliance concern.

Patients have the right to: • Ask to see and receive a copy of their health records • Have corrections added to their health information • Receive a notice that tells them how their health information may

be used and shared • Decide if they want to give their permission before their health

information can be used or shared for certain purposes, such as marketing

• Get a report on when and why their health information was shared for certain purposes

Patients’ HIPAA Rights

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Violations of a Patient’s HIPAA Rights can be reported like any other compliance concern.

If a patient believes their rights are being denied or their health information is not being protected, they can file a complaint with MHS Corporate Compliance Department or the Department of Health and Human Services (HHS) at www.hhs.gov

Patient Reporting Contact Information: → Corporate Compliance

at ext. 11983

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All associates are obligated to report unexpected, unanticipated events that either did result in harm, or have potential to result in harm (near miss) including:

– Adverse Incidents (can include Code 15 incidents)

– Sentinel Events – Grievances – Professional Conduct Concerns – Threats of litigation – Suspicion of neglect or abuse – Suspicions of suicide risks – Patient or visitor falls – Lost valuables – Allegations of sexual misconduct – Medication variances – Surgical or procedure complications

Your Obligation to Report

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Patients have the right to:

• Know their diagnosis, treatment plan, alternatives, risks, and prognosis

• Refuse treatment

• Treatment for an emergency medical condition that will deteriorate from failure to provide treatment

• Effective pain management

• A patient has the right to designate and receive visitors of their choosing. Visitors will be allowed equal access regardless of race, color, national origin, religion, sex, gender identity, sexual orientation or disability, subject to hospital visitation policies. (this includes their support person)

• (Refer to Patient’s Bill of Rights and Responsibilities for full list which is located in the patient’s guide and in the ED and admitting lobbies)

Patient Bill of Rights and Responsibilities

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Violations of a Patient’s Bill of Rights and Responsibilities can be reported through the Occurrence Reporting method

• If an Error or Unexpected Event Occurs (including Adverse Incident or Sentinel Event)

– Take care of the patient first – Notify your supervisor and the physician

What to do: If an Error or Unexpected Event Occurs

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If you have a work-related injury, illness, or exposure:

1. Notify your leader at once 2. For blood/body fluid exposure, follow BLEX Quick Reference 3. Seek treatment

a) In case of emergency, go to your nearest emergency room! Then follow the procedure described below.

b) Contact Occupational Health at 223-5945, ext. 14812 immediately to help coordinate your care.

c) If after 5pm or weekend/holiday: Call the hospital operator and ask for the on-duty nursing supervisor to help you coordinate your care. Follow up with Occupational Health, ext. 14812, the next business day.

Note: • Treatment must be authorized by Occupational Health. • Call Occupational Health for follow up. • All injuries must be reported. Failure to report your injury timely could jeopardize your

benefits.

What to do: If there is a Work-related Injury, Illness, or Exposure

Contact Information: → Occupational Health ext.

14812

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Patient Complaint vs. Grievance

Complaint

A complaint is: an issue that is unrelated to patient care.

Examples: • Housekeeping of a room • Food preferences • Billing issues

Grievance A grievance is: an issue that is related to patient care, but was not resolved by the staff that was present at the time of the issue. Examples: • Unmet patient care expectations • Premature discharge • HIPAA concerns • Lack of informed consent

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All written complaints are grievances (an email or fax is also considered a written complaint)

Please report grievances to your supervisor as soon as you receive them. The hospital must respond to grievances within a reasonable time frame (average of 7 days or less) and review, investigate, and resolve each patient’s grievance within a reasonable timeframe.

Patient Grievance

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